What orthopaedic surgeons, practice managers, and staff want to know

In this article, we discuss five concerns from surgeons and their staff that are currently “trending.”

1. Vendor advice = a flashing yellow light

Question: Our orthopaedic surgeon recently performed a single-level anterior cervical diskectomy and fusion and reported Current Procedural Terminology (CPT) codes 22853 and 22845 for the intervertebral biomechanical device and anterior instrumentation. When I look up the device name, it includes the description “low profile,” and I don’t see documentation for, or the name of, a separate plate in the operative note. The physician told me the vendor said it is okay to report both codes. Is this correct?

Answer: When reporting plate instrumentation in conjunction with insertion of intervertebral biomechanical devices, specific criteria must be met to support reporting an additional code. The CPT description of 22853 includes the phrase, “with integral anterior instrumentation for device anchoring (e.g., screws, flanges).” This means that integrated fixation of the biomechanical device is included in that CPT code. CPT code 22845 is only reportable when key criteria are met, including the instrumentation must be able to provide support on its own, it must be usable with other vendor devices, and it must span the interspace. Medicare created a National Correct Coding Initiative guideline between the intervertebral biomechanical device codes (22853 and 22854) and the anterior instrumentation codes (22845, 22846, and 22847) in March 2017 to reflect the fact that specific criteria must be met to allow separate reporting.

2. Shoulder issues

Question: Is there a CPT code for arthroscopic reduction and internal fixation of a greater tuberosity fracture?

Answer: The only body areas that have arthroscopic fracture treatment codes are the wrist (29847) and knee (29850–29856). For arthroscopic reduction and internal fixation of a greater tuberosity fracture in the shoulder, you should use unlisted code 29999 and compare it to the open treatment code.

3. Coders as diagnosticians?

Question: As a coder, can I put together the details of an evaluation and management note to assign a diagnosis code? For example, the documentation indicates the patient is 42 years old with a body mass index of 42 mg/k². The physician documented that the patient has severe arthritis in the right hip. Can I assign the code for secondary osteoarthritis (OA), indicating that the arthritis is a result of the morbid obesity? The physician documented that a 48-year-old male was in a motor vehicle accident when he was 22 years old and suffered a closed comminuted right proximal femur fracture that was fixed with plate and screws. The hardware was previously removed without problems. The provider’s documentation states severe OA of the right hip. Can I assign the International Classification of Diseases, 10th Revision, Clinical Modification (or ICD-10-CM) code for post-traumatic OA of the right hip, indicating that the arthritis is a result of the earlier accident?

Answer: The answer to both questions is no. The coder is not allowed to draw conclusions by piecing together details of the record. There must be a specific statement from the doctor or provider linking the cause to the effect. In these cases, the provider would have to state that the patient had secondary OA or post-traumatic arthritis in the documentation. A coder cannot draw this conclusion on his or her own.

4. Plan-mandated outpatient TKAs?

Question: We have difficulty precertifying total knee arthroplasty (TKA) for inpatient stays. Medicare Advantage plans say TKA must be performed in the outpatient setting, according to guidelines released on Jan. 1. Is this correct?

Answer: No. TKA was removed from the inpatient-only (or IPO) list as of Jan. 1. Medicare was very clear in the federal register that it has not and will not develop guidelines identifying patients who should have TKA performed in an outpatient setting. It indicated that “specialty societies and providers” should work together to create these guidelines and that the physician is the best person to make the determination about appropriate place of service.

Question: There is a lot of confusion in our office when the doctor injects viscosupplementation and it is not covered by a plan. The physicians want to report code 20610 to the payer for the injection and have the patient self-pay for the drug. Our billers do not believe this practice is correct and think the entire service should be self-pay—drug and injection. If you agree with the billers, is there anything we can use to convince our surgeons that they should not be billing the payer for the injection?

Answer: This is a frequent question that reveals confusion regarding appropriate coding. We agree with the billers. When the payer indicates that a drug is experimental or not considered “reasonable and necessary” and, therefore, is not covered, why would one think it okay to bill the mode of administration of the uncovered drug? There is documentation to support this line of thinking in the Medicare Carrier Manual: 50.4.3 Examples of Not Reasonable and Necessary. It says, “If a medication is determined not to be reasonable and necessary for diagnosis or treatment of an illness or injury according to these guidelines, the Medicare administrative contractors (MAC) that process Part A and Part B claims (A/B [B]) or durable medical equipment excludes the entire charge (i.e., for both the drug and its administration). Also, MAC A/B (B) exclude from payment any charges for other services (such as office visits), which were primarily for the purpose of administering a noncovered injection (i.e., an injection that is not reasonable and necessary for the diagnosis or treatment of an illness or injury).”

Margaret Maley, BSN, MS, and Sarah Wiskerchen, MBA, CPC, are senior coding consultants with KarenZupko & Associates, Inc. They develop and teach the Academy’s annual coding and reimbursement workshops and specialize in orthopaedic coding, documentation, and reimbursement.